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S / <br />( l:p�L✓ileac Call:wcvd !;iun SebmlttcE Properly Completed.Be Sure To Sign The Application. <br /> SAN .SOA a:U E4 LOCAL -HEALTH DISTRICT <br /> ENGINEER'S AND/OR GENERAL <br /> 1 APPLICANT'S AND/OR r`::'.'t L:CFE i(Gl y' IF VEHICLE INVOLVED. GIVE <br /> I ITNACTOH AND/On -4. 511 0��0:•.�ti�rL HEALTH PERNINT/SCRVICES Make <br /> + C'cusc Aho/OR E:' T _,.T L.I B LIC NO. ___- <br /> REGISTRATION ,:c vocl„ .:hL.S Regis:. No. <br /> NUMBER ^•.• ZS Tf1T[L:Sl:C'.:a:': COIdr— —_-- <br /> ' PceLT.Y f.:dCaE3 A"a —'- <br /> - A lam' 7ICCZLL,JEBJs SEAvicES <br /> PPlicalion Date ^� _ Businca /Name To A r • ! i 1 t I_.� / <br /> ppear On Permit �- <br /> sType Permit/Service Requc c.d <br /> -App'lcenl Name Addresa // =­x4, <br /> G '—�— --� t- Business Telephone,o !: ph <br /> �� -�i�, i r' Emergency Teleone No. --' - � 1 <br /> ,r Property Location/Address / /r - <br /> Properly Owner n- ' ' - nT�1 <br /> ---,-- _ Address .� - -Ir•�-. <br /> L Operator's Name '`_• _( a '..-�I Lz Address r�'�J� . J J __r; ice ' > •"r <br /> 1. FOOD.,ESTAD.ISH.,aNTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity _ <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> n FCCD PROCESSING PLANT' C1 COMMISSARY C3 ICE PLANT ❑ BAKERY <br /> Q ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION - ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. 01 ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE" <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators I <br /> 2.. HOUSING <br /> --- ❑ <br /> HOTEL/MOTEL/No.of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL - <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> v <br /> NO.OF PUBLIC SERVED(Connections) <br /> G. RaC4EATtON'AL HZALTH ❑ SWIMMiNG POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> VECYORCONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> KENNEVRunways iAnimal Population No. No.of Confining Cages — <br /> Sewage Disposal Mctncd <br /> Solid Waste Disposal Method - <br /> Water Supply Source , Animal Waste Disposal Method <br /> 6. .`CONSULTATION FEE 'r- ` •� .r hL —% ❑ <br /> =r5BUSINESS LICENSE ry <br /> T.-' -1 PLAN CHECKING FEE <br /> • ,r DANCE PERMIT <br /> . 1 <br /> S. <br /> REAL ESTATE <br /> REQUEST:. .Water Wall Inspacticn❑ Sampla❑ Title Company <br /> Sewage Sysiem Inspection ❑ Address Tele.No. <br /> Escrow NO. - ' <br /> . . f. Seller Seller Address <br /> Telephone No. Seller Agent Name,_ ' <br /> Service Requost For Date _ <br /> y <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> `- ordinances•stale laws and ruler and regulations of the San Joaquin Local Health District <br /> APPLICANTS SIGNATURE IX J/ - >' Tlllo�i , ;.r//jl:-a�,A,.Date <br /> Fi <br /> - FOR DEPARTP.:ENT USE ONLY r ,_ <br /> FCO 19 Dee:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I&Received By January 31, ,[) JUIy I'iS'.IR ci S[E .(y July 31 <br /> BILLING REMITTANCE' f ' I'. Pl�rlT _ 1 <br /> BASE EXPLANATION DATE DATE REMITTED .`AMOUNT OUE f{1ECjKED F1r11 <br /> FEE iA'y AMO NIT <br /> �. i'11 OCTV <br /> LESS - —_ <br /> PRORATIONPLUS E7 <br /> I - <br /> PENALTY y <br /> OTHER _.. I :S <br /> 3 OTHER <br /> fl CC •J by Ddla n c.l' b 1 I Nn Issuance Ogle lAellad Delivered / M <br /> APPL:CAar-P.CT—.Ill a i.aTO: ... L.C. _:ITA1.xEALTH PEL.eT SERVICES 1401 E.HAZELTON AVE..P.O.a*a 20JD S:OCSTON,CA95201 - <br /> I <br />